17 April 2008

I recently cared for a young boy with abdominal pain. He was about six years old, and had pain in his lower abdomen for about 12 hours prior to coming to the ER. His parents, Ukranian immigrants, were really nice people. Their English could have been a little better, but we could understand one another perfectly with a little effort and we got along fine. They were among the nicest people I have had the pleasure of interacting with in the ER in a long time. They were reserved, polite, and deeply respectful towards me in a manner that struck me as almost old-fashioned, and they were very concerned about their son, their only child, who was in a lot of pain and had never been ill like this before.

I was almost certain that he had appendicitis, and after explaining this to the parents, I called the surgeon to see if we could just take him to the OR for a laparotomy. You may recall I've run into trouble with this sort of thing before, and the surgeon, the same surgeon as before, wouldn't bite this time. In fairness, the story wasn't quite perfect -- the pain didn't localize quite right, the white count wasn't really high enough, etc -- so she asked me to image the child to verify the diagnosis, which is reasonable.

In the interim, a large contingent of extended family had congregated in the ER; they were also polite and stayed out of our way. I explained that we would be doing an ultrasound on his abdomen to try to see if the appendix was inflamed. Unfortunately, it took a while to get the study, and is often the case, it was non-diagnostic. Often the appendix "hides" behind the cecum and the sono tech just can't visualize it.

So I went back into the room and told the family that we would need to do a CT scan. They had been in the ER for several hours now and were beginning to get a bit frustrated by the lack of any apparent progress; their son was still hurting and we hadn't "done" anything for him. (Though he had had fluids, pain medicine, and antibiotics.) Still unfailingly polite, but a bit frayed, they wanted to know why, if a CT scan was more precise, we hadn't just done it in the first place.

I explained that since he was young, there was a high value placed on avoiding radiation and a CT scan involves a fair amount of ionizing radiation; since a ultrasound does not have radiation, we do that study first, and only do a CT if it's necessary.

As I said this, they stiffened, and their whole demeanor changed, from incredulity, to fear and outright hostility. The mother immediately said that she was taking her boy home and began bundling him up -- only the presence of the IV catheter keep her from storming out; she couldn't quite figure out how to get it out. The father started yelling at me angrily, but I couldn't quite understand his gist. I was stunned. Nothing in our interaction had prepared me for a behavior shift like this, and I had no idea how to defuse it, or even where it had come from. We talked past each other for a minute or two until one of the teenaged relatives took me by the elbow and led me outside the room.

"You have to understand their feelings about radiation. It scares them a lot. They are from Kiev, in the Ukraine." He looked at me expectantly, but I didn't get it at first.

Oh.

"Chernobyl?" I ventured. He nodded.

No wonder they were freaked out by the mention of radiation.

We went back into the room. By that time some other family members had managed to calm the parents down. I tried to give them the logical take on radiation doses, risks versus benefits, and all that, but their rational brains had clearly shut down. Finally, lacking anything else, I pointed out that I had a five-year-old son, and if it were my son with the same pains, I would not hesitate to put my son in the scanner.

That did it. It was all they needed to hear and they trusted me again. If "the doctor" would do it for his own son, then it must be OK. All of a sudden they were happy and content again, signed the papers for the test, and off they went to the scanner, which confirmed the appendicitis.

Several days later, they tracked me down in the ER and brought me some savory pastry things to eat. I don't know what they were, but they were delicious.

MRIs are tough to get. They are time consuming, which translates to limited availability -- there are only so many studies each scanner can do a day, and they are often not staffed at night unless there is a true emergency (i.e. spinal injury). Also, the tube is narrow and the study takes a while, so I don't think I would expect a 6 year old to be able to tolerate it without sedation, itself a risk.

So Abdominal MRIs are pretty damned rare, and not a great practical solution.

Its kind of a sad commentary on the state of American's awareness in general that when Ukranian parents panicked at the mention of radiation you needed to be told it had to with Chernobyl.

A few years ago I had a Ukranian patient with a nose bleed that would not stop. I said to the doctor, shouldn't we get a cbc because of the high probability of a blood dyscrasia. He was clueless. Needless to say, they had a nasty leukemia and no platelets.

I see Ukranian patients every day -- we have a big population here -- so their cultural background didn't seem uncommon and I didn't give it any thought. Then when they started freaking out, I wasn't clear at all why. It wasn't till I put the two together that it made sense.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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